Provider Demographics
NPI:1598158453
Name:GORDON, JACLYN D (PA-C)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:D
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:D
Other - Last Name:MCAULIFFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:115 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6358
Mailing Address - Country:US
Mailing Address - Phone:508-532-6626
Mailing Address - Fax:
Practice Address - Street 1:115 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6358
Practice Address - Country:US
Practice Address - Phone:508-532-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant